Please note: Health plan authorization typically takes 5 to 15 business days (or more). Once approved, you will receive the service for 90 days, which includes 6 in-home chef visits with meals and cooking lessons.
To get the full benefit, it's important to start using the service as soon as possible after approval. Unused visits do not roll over and will expire at the end of the 90-day period.
1. Service Description
I understand that I am enrolling in a Medically Tailored Meals (MTM) and Cooking Education service provided by Foodom, where a professional chef will:
- Prepare meals based on my specific dietary needs and health conditions as recommended by my healthcare provider.
- Provide in-home cooking education, teaching me how to cook homemade meals.
- These services are designed to support my medical condition(s) but are not a substitute for medical treatment or nutrition counseling.
2. Consent to Receive Services
I voluntarily agree to participate in the MTM and Cooking Education program and receive medically tailored meals and/or in-home cooking lessons. I understand that:
- Meals are based on dietary requirements provided by my healthcare provider.
- The service includes both meal preparation and optional cooking education to help me or my caregiver develop skills for long-term health management.
- My participation is optional, and I may withdraw at any time.
3. HIPAA & Data Privacy Consent
I authorize Foodom and its independent contracted providers to receive, use, and share relevant Protected Health Information (PHI) with my healthcare provider, insurance plan, and program administrators as necessary for the delivery of medically tailored meal services and cooking education.
This may include:
- Dietary restrictions related to my medical condition(s).
- Health information required for program eligibility and billing purposes.
- Feedback on meal preferences and program effectiveness.
I understand that my PHI will be kept confidential and only used as necessary to provide these services in compliance with HIPAA regulations.
4. Notice of Privacy Practices & Patient Rights
Foodom’s Notice of Privacy Practices (NPP) provides information about how we may use and disclose your PHI.
You have the right to:
- Review our Privacy Practices before signing this consent.
- Request restrictions on how your PHI is used or shared. While Foodom is not required to agree to all requests, we will honor any agreed-upon restrictions.
- Revoke your consent at any time by notifying Foodom in writing. However, any disclosures made before revocation will remain valid.
You can review Foodom’s Privacy Practices here:
https://www.myfoodom.com.
5. Kitchen Requirements for Safe Meal Prep
To ensure my health and safety, I acknowledge that my kitchen must meet the following standards:
- Clean, sanitary, and pest-free for safe food preparation.
- A working refrigerator (38°F or below) and freezer space for at least 16 meals each.
- A functional stovetop and oven.
I understand that if my kitchen does not meet these minimum requirements, I will not be able to participate in this program.
6. Food Safety, Cooking Education & Liability Release
I acknowledge that:
- All meals are prepared following food safety guidelines, but I am responsible for proper storage and reheating of meals.
- Cooking education sessions involve the use of kitchen equipment, and I will follow the safety instructions provided by the chef.
- I will notify Foodom and the chef of any food allergies or dietary restrictions before receiving meals or participating in cooking education.
- I am responsible for reviewing the ingredients of the meals on the Foodom menu and for selecting the appropriate meals for my dietary needs.
- Foodom and its chefs are not responsible for adverse reactions due to allergies or sensitivities or due to any other reasons.
- I assume responsibility for any risks associated with cooking activities conducted in my home.
7. Right to Withdraw
I understand that I may choose to discontinue my participation in this program at any time by notifying Foodom at
health@myfoodom.com.
8. Consent & Signature
By signing below, I acknowledge that I have read and understand this consent form. I agree to participate in the Medically Tailored Meals & Cooking Education Program and authorize the use and disclosure of my Protected Health Information (PHI) as necessary for treatment, payment, and healthcare operations, including coordination with my healthcare provider, insurance plan, and program administrators. I understand that I have the right to revoke this consent at any time by providing a written, signed notice. However, I acknowledge that any disclosures made prior to my revocation will remain valid.
